Tag Archives: anesthesiology

A New Era for Regional Anesthesiology and Acute Pain Medicine

It has finally happened–the inaugural class of ACGME-accredited Regional Anesthesiology and Acute Pain Medicine (RAAPM) fellowships has been announced, marking the beginning of a new era.

Congratulations to the following 9 programs that now are the first accredited fellowship programs representing this subspecialty in the United States:

  1. Stanford University
  2. Cedars-Sinai Medical Center
  3. University of California, San Francisco
  4. Massachusetts General Hospital
  5. Brigham and Women’s Hospital
  6. Montefiore Medical Center/Albert Einstein College of Medicine
  7. Icahn School of Medicine at Mount Sinai/St. Luke’s-Roosevelt Hospital
  8. Duke University Hospital
  9. Vanderbilt University Medical Center

Accreditation is immediate and retroactive to the current 2016-17 academic year. This announcement represents a tremendous achievement in anesthesiology training and medical education in general.  Nearly 4 years ago, at our spring RAAPM fellowship directors meeting in 2013, I was appointed to lead the task force that would eventually make contact with the ACGME to request consideration for accreditation of our subspecialty fellowship programs. After submitting the 161-page letter to ACGME, we waited nearly a year to receive a response, and it was positive. The next 2 years were spent drafting the program requirements that would eventually be used as the basis for fellowship design and evaluation. This was an iterative process with multiple revisions based on solicited feedback and public commentary.

When the application period opened for the first time ever in October 2016, programs interested in applying had less than 2 months to prepare their program information forms and other materials, have them reviewed and approved by their local graduate medical education offices, and submit to ACGME in time for the 2017 spring review.

These 9 accredited programs have embarked on a brave new path, but it will not be an easy one. Their programs will be reviewed periodically to evaluate adherence to the program requirements and the quality of fellowship training, and deficiencies identified will need to be resolved or face loss of accreditation. However, their commitment to maintaining accreditation represents, in my opinion, a commitment to their fellows that they will provide a training experience that can be held as a benchmark for all programs.

We need our fellowship training programs to develop leaders in regional anesthesiology and acute pain medicine who can catalyze changes in healthcare that will improve patient outcomes and experience. Today, we have taken a huge step forward.

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Changing Clinical Practice Doesn’t Have to Take So Long

Guest post by Seshadri Mudumbai, MD, MS.  Dr. Mudumbai is an Assistant Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine. He is also a health services researcher and physician anesthesiologist at the Veterans Affairs Palo Alto Health Care System.

time-for-changeChanging physician behavior is rarely easy, and studies show that it can take an average of 17 years before research evidence becomes widely adopted in clinical practice. One study published in JAMA has identified 7 categories of change barriers:

  1. Lack of awareness (don’t know guidelines exist)
  2. Lack of familiarity (know guidelines exist but don’t know the details)
  3. Lack of agreement (don’t agree with recommendations)
  4. Lack of self-efficacy (don’t think they can do it)
  5. Lack of outcome expectancy (don’t think it will work)
  6. Inertia (don’t want to change)
  7. External barriers (want to change but blocked by system factors)

Why Change?

According to the Institute of Medicine’s Crossing the Quality Chasm: a New Health System for the 21st Century:  “Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.”  Our group has focused our efforts on implementing updated evidence-based medicine initiatives for surgical patients with a special emphasis on the total knee replacement population.  Knee replacement is already one of the most common types of surgery in the United States (over 700,000 procedures per year).  Given an aging population, the volume of knee replacement surgeries is expected to increase to over 3 million by the year 2030.

We now have sufficient evidence to support “neuraxial anesthesia” (such as a spinal or epidural) as the preferred intraoperative anesthetic technique for knee replacement patients.  With neuraxial anesthesia, an injection in the back temporarily numbs the legs and allows for painless surgery of the knee.  Several studies have now shown better outcomes and fewer complications after knee replacement surgery with neuraxial anesthesia when compared with general anesthesia.  Despite these known benefits, a large study evaluating data from approximately 200,000 knee replacement patients across the United States reveals that use of neuraxial anesthesia occurs in less than 30% of cases.  At our facility prior to changing our practice, we noted a 13% rate of neuraxial anesthesia utilization.  In the face of growing evidence, we chose to change our practice, and the results of these efforts are reported in our recently published article.

How Did We Start?

An important tool used to coordinate the perioperative care of knee replacement patients has long been the clinical pathway.  A clinical pathway is a detailed care plan for the period before, during, and after surgery that covers multiple disciplines:  surgery, anesthesiology and pain management, nursing, physical and occupational therapy, and sometimes more.   The concept of the clinical pathway should be dynamic and not static.  This requires a process to ensure clinical pathways are periodically updated and someone to take a leadership role in managing the process.

At our institution, we established a coordinated care model known as the Perioperative Surgical Home (PSH).  The PSH provides the overall structure and coordination for perioperative care, and multiple clinical pathways exist within this structure.  With a PSH, physician anesthesiologists are charged with providing leadership and oversight of specific clinical pathways, collecting and reviewing data, engaging frontline healthcare staff and managers across disciplines, and suggesting changes or updates to clinical pathways as new evidence emerges.

Within our PSH model, we invested in a 5 month process to change our preferred anesthetic technique from general anesthesia to neuraxial anesthesia within the clinical pathway for knee replacement patients.  This process involved many steps and followed the Consolidated Framework for Implementation Research:

  1. Literature review and interdepartmental presentation
  2. Development of a work document
  3. Training of staff
  4. Prospective collection of data with feedback to staff.

After one year, the overall percentage of knee replacement patients receiving neuraxial anesthesia increased to 63% from 13%, and a statistically-significant increase in neuraxial anesthesia use took place within one month of the updated clinical pathway rollout.

How Do We Keep It Going?

Neuraxial anesthesia continues to be the predominant anesthetic technique that our knee replacement patients receive today.  We attribute the ongoing success of this change to multidisciplinary collaboration, physician leadership in the form of a departmental champion, peer support and feedback, frequent open communication, and engagement and support from facility leadership.  The results of our study and experience show that a PSH may help facilitate changes in clinical practice quicker than other less-coordinated models of care.  As PSH models continue to be developed, further evidence to support the impact of clinical practice changes on patient-oriented outcomes related to quality and safety and healthcare economics is needed.

For patient education materials regarding anesthetic options for knee replacement surgery, please visit My Knee Guide.

 

 

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Physician-Led Anesthesia is Safe Anesthesia

Anesthesia1Many people, even those who work in the operating room every day, take safe anesthesia care for granted.  There has been growing pressure recently to abandon the team model and remove physician anesthesiologists’ supervision of nurse anesthetists with the latest threat coming from within Veterans Affairs (VA) healthcare.  For our Veterans, our heroes and arguably some of the most medically complex patients, having both physician anesthesiologists and nurse anesthetists working together as a team makes sense.

Having a team with members who train differently and have different perspectives can only benefit the patient; physician anesthesiologists draw on their medical training while nurse anesthetists bring valuable nursing experience.  Providing anesthesia is often compared to flying a passenger airplane, and the care team model is like having both a pilot and a co-pilot.  Has flying become so safe that we no longer need the pilot?  Seconds count in flight, and they count in the operating room when a patient’s life is on the line.  If approved, the proposed change in the VA nursing handbook will abolish this team model without giving Veterans a choice and will require VA hospitals to assign Veterans having surgery either a nurse anesthetist OR a physician anesthesiologist but not offer both.  If they were given the choice, however, I think our Veterans would choose “AND” instead of “OR.”  We all should.  In case a crisis happens during surgery, every patient should have access to a physician anesthesiologist.

Not too long ago operating room personnel had to worry about explosive anesthetic gases, and patients faced the risk of developing organ failure after every time they had anesthesia in addition to the usual perils of having surgery.  This changed when anesthesiology became a medical specialty and profession for physicians.

How is anesthesiology different than anesthesiaAnesthesia, a word with Greek origin, means “without sensation.”  Often referred to as “going to sleep,” general anesthesia is more like a complex drug-induced coma that can still carry serious risk, and a person’s physical and emotional reactions to anesthetic agents are not always predictable.

Anesthesiology is a science like biology or physiology and a specialty field of medicine like cardiology or radiology.  Modern anesthesiologists are physicians, scientists, educators, and patient safety advocates.  The heart of anesthesiology continues to be the patient experience.  As physician anesthesiologists, we specialize in relieving anxiety, preventing and treating pain, preventing and managing complications related to surgery, and improving the outcomes for patients who undergo invasive procedures.  The average physician anesthesiologist spends nearly a decade in postgraduate education after college and logs 16,000 hours of clinical training to learn to apply the best available evidence in clinical practice.  Academic physicians and scientists focused on anesthesiology are responsible for the discovery of the newer and safer anesthetic and analgesic agents we use every day.

Anesthesia administration by non-physicians such as nurse anesthetists and certified anesthesiologist assistants is supported by the American Society of Anesthesiologists within the physician-led anesthesia care team model.  A similar model is used in the intensive care unit with physician intensivists supervising teams that include acute care nurse practitioners.  To preserve safe, high-quality physician-led anesthesia care for our nation’s Veterans, please support the team model and #SafeVACare by speaking up on http://www.safevacare.org by July 25th.  It only takes a minute to post a comment, but the consequences of not saying something may be serious and long-lasting.

This post has also been featured on KevinMD.com.

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The Future of Acute Pain Medicine Training

AVC.Pain_We all know that not all pain is the same. While chronic pain can sometimes be palliated, “acute” pain (new onset, often with an identifiable cause) must be aggressively managed and, ideally, eliminated. This requires a systems-based approach led by physicians dedicated to understanding acute pain pathophysiology and investigating new ways to treat it. 

In December 2013, I submitted a 161-page letter to the Accreditation Council for Graduate Medical Education (ACGME) requesting that regional anesthesiology and acute pain medicine be considered for fellowship accreditation, with a lot of help from a small group of fellowship directors and colleagues from obstetric anesthesiology who recently went through the ACGME accreditation process for their fellowships. With no requests for further information, the Board of Directors of the ACGME informed me in the fall of 2014 that Regional Anesthesiology and Acute Pain Medicine (RAAPM) will be the next accredited subspecialty fellowship within the core discipline of Anesthesiology.  The draft program requirements have been posted online for public comments.  After the comment period, these program requirements will be revised and then finalized for posting by the ACGME. At that point, which may be as early as the end of this year, institutions with RAAPM fellowships will be invited to apply for accreditation.

I have received many questions from ASRA members about this process to date, so below I have provided some of my answers to the most common ones:

Why do we need “another” fellowship dedicated to pain medicine?  Although we already have a board-certified subspecialty of Pain Medicine within Anesthesiology, there is a growing demand for physicians who specialize in hospital-based acute pain medicine. For Pain Medicine fellows, the required “Acute Pain Inpatient Experience” may be satisfied by documented involvement with a minimum of only 50 new patients and the spectrum of pain diagnoses and treatments that they are required to learn during one year is vast. Further, Pain Medicine is a board-certified subspecialty of Emergency Medicine, Family Medicine, Physical Medicine and Rehabilitation, and Psychiatry and Neurology, in addition to Anesthesiology; graduates from any of these residency programs can be accepted into the one-year Pain Medicine fellowship and will not be as familiar with surgical or trauma-induced acute pain as an anesthesiology residency graduate. Anesthesiology is a hospital-based medical specialty, and anesthesiologists are physicians who focus on a  daily basis on the prevention and treatment of pain for their patients who undergo surgery, suffer trauma, or present for childbirth. History also supports the evolution of acute pain medicine through anesthesiology. The concept of an anesthesiology-led acute pain management service was described first in 1988 (1), but arguably the techniques employed in modern acute pain medicine and regional anesthesiology date back to Gaston Labat’s publication of Regional Anesthesia: Its Technic and Clinical Application in 1922, with advancement and refinement of this subspecialty in the 1960s and 1970s (2-6). Finally, a recent survey study shows that the great majority (83.7%) of practicing pain physicians in the United States focus only on chronic pain (7).

Why do anesthesiology residency graduates still need to do a fellowship in RAAPM? By the time they complete the core residency in anesthesiology today, not all residents have gained sufficient clinical experience to provide optimal care for the complete spectrum of issues experienced by patients suffering from acutely painful conditions, including the ability to reliably provide advanced interventional techniques proven to be effective in managing pain in the acute setting (8-12). We need physician leaders who can run acute pain medicine teams and design systems to provide individualized, comprehensive, and timely pain management for both medical and surgical patients in the hospital, expeditiously managing requests for assistance when pain intensity levels exceed those set forth in quality standards, or to prevent pain intensity from reaching such levels. The mission statement for the Acute Pain Medicine Special Interest Group within the American Academy of Pain Medicine provides clear justification.

Will RAAPM fellowship graduates get jobs when they are done? Although no one can make this guarantee, there are good reasons to think that there will be growing demand for RAAPM graduates in the future. In a survey of fellowship graduates and academic chairs published in 2005, 61 of 132 of academic chairs responded (46%), noting that future staffing models for their department will likely include an average of two additional faculty trained in regional anesthesiology and acute pain medicine (13). RAAPM fellowship graduates are the only physicians who can say that their subspecialty training is entirely dedicated to improving the patient experience. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is administered to a random sample of patients who have received inpatient care and receive government insurance through Center for Medicare and Medicaid Services (CMS). The survey consists of 32 questions and is intended to assess the “patient experience of care” domain in the value-based purchasing program. A hospital’s survey scores are publicly disclosed and make up 30% of the formula used to determine how much of its diagnosis-related group payment withholding will be paid by CMS at the end of each year. Of the 32 questions, 7 directly or indirectly relate to in-hospital pain management.

Are we ready for accreditation? Currently, there are over 60 institutions in the United States and Canada that list themselves as having nonaccredited fellowship training programs focused on RAAPM on the ASRA website. Since 2002, the group of regional anesthesiology and acute pain medicine fellowship directors has been meeting twice yearly at the ASRA Annual Spring Meeting and the American Society of Anesthesiologists (ASA) Annual Meeting in the fall. Despite not being an ACGME-accredited fellowship, this group, has been voluntarily engaged in developing and refining training guidelines as the foundation for the fellowship. These guidelines, originally published in Regional Anesthesia and Pain Medicine in 2005 (14) with a revision in 2011 (15) have been recently released as the third edition (16). Formal ACGME program requirements will serve as a measuring stick to hopefully ensure that the certificates that RAAPM fellowship graduates receive from all accredited programs will share some common value.

As with other medical subspecialties, acute pain medicine has emerged due to the need for trained specialists—in this case, those who possess the knowledge, skills, and abilities to efficiently manage a high volume of inpatient consultations, anticipate the analgesic needs of a wide range of patients based on preoperative risk, use a multimodal approach to manage and prevent pain when possible, and aggressively treat severe acute pain when it occurs to prevent it from transitioning into chronic pain. The RAAPM fellowship graduate must be a physician leader who is capable of collaborating with other healthcare providers in anesthesiology, surgery, medicine, nursing, pharmacy, physical therapy, and more to establish multidisciplinary programs that add value and improve patient care in the hospital setting and beyond.

This article originally appeared in the February 2016 issue of ASRA News.  As of October 2016, the regional anesthesiology and acute pain medicine is the newest accredited subspecialty fellowship within anesthesiology, and programs may now apply for accreditation to the ACGME.

REFERENCES

  1. Ready LB, Oden R, Chadwick HS, Benedetti C, Rooke GA, Caplan R, Wild LM. Development of an anesthesiology-based postoperative pain management service. Anesthesiology. 1988; 68:100-6.
  2. Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technic of lumbar plexus anesthesia: the “3-in-1 block.” Anesth Analg. 1973; 52:989-96.
  3. Winnie AP, Collins VJ. The subclavian perivascular technique of brachial plexus anesthesia. Anesthesiology. 1964; 25:353-63.
  4. Raj PP, Montgomery SJ, Nettles D, Jenkins MT Infraclavicular brachial plexus block–a new approach. Anesth Analg. 1973; 52:897-904.
  5. Raj PP, Parks RI, Watson TD, Jenkins MT. A new single-position supine approach to sciatic-femoral nerve block. Anesth Analg. 1975; 54:489-93.
  6. Raj PP, Rosenblatt R, Miller J, Katz RL, Carden E. Dynamics of local-anesthetic compounds in regional anesthesia. Anesth Analg 1977; 56: 110-7.
  7. Breuer B, Pappagallo M, Tai JY, Portenoy RK. U.S. board-certified pain physician practices: uniformity and census data of their locations. J Pain. 2007; 8: 244-50.
  8. Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol. 2009; 22: 588-93.
  9. Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, Hanssen AD, Horlocker TT. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med. 2008; 33: 510-7.
  10. Jin F, Chung F. Multimodal analgesia for postoperative pain control. J Clin Anesth. 2001; 13: 524-39.
  11. Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg. 1993; 77: 1048-56.
  12. Young A, Buvanendran A.Recent advances in multimodal analgesia. Anesthesiol Clin. 2012; 30: 91-100.
  13. Neal JM, Kopacz DJ, Liguori GA, Beckman JD, Hargett MJ. The training and careers of regional anesthesia fellows–1983-2002. Reg Anesth Pain Med. 2005; 30: 226-32.
  14. Hargett MJ, Beckman JD, Liguori GA, Neal JM. Guidelines for regional anesthesia fellowship training. Reg Anesth Pain Med. 2005; 30: 218-25.
  15. Regional Anesthesiology and Acute Pain Medicine Fellowship Directors Group. Guidelines for fellowship training in regional anesthesiology and acute pain medicine: second edition, 2010. Reg Anesth Pain Med. 2011; 36: 282-8.
  16. Regional Anesthesiology and Acute Pain Medicine Fellowship Directors Group. Guidelines for fellowship training in regional anesthesiology and acute pain medicine: third edition, 2014. Reg Anesth Pain Med. 2015; 40: 213-7.

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Pain Medicine, Perioperative Surgical Home, and the Patient Experience

VAPAHealthcare around the world is changing. In the United States, healthcare reform has been focused on achieving the “triple aim” as described by Berwick (1). This triple aim encompasses 3 goals: improving the patient experience, reducing costs of care, and improving population health. The Perioperative Surgical Home (PSH) is a conceptual model introduced by the American Society of Anesthesiologists (ASA) in the past 5 years that may serve as an integrator to help hospitals achieve the triple aim (2). PSH is defined as “a patient-centered, physician anesthesiologist-led, multidisciplinary team-based practice model that coordinates surgical patient care throughout the continuum from the decision to pursue surgery through convalescence” (3). In reality, a PSH can take many forms, and the concept is analogous to the “Perioperative Medicine: the Pathway to Better Surgical Care” initiative by the Royal College of Anaesthetists in the United Kingdom. To date, there have been few published descriptions of actual PSH programs.

Role of Pain Medicine in the PSH

Pain medicine is woven throughout the three main elements of the PSH: preoperative preparation, intraoperative care, and postoperative recovery and rehabilitation (4). Preoperatively, anesthesiologists and pain medicine specialists have an opportunity to influence patient care by identifying patients who are considered high risk for surgery and tailor an individualized preoperative preparation plan for them. For example, the patient with chronic pain treated with long-acting opioids may benefit from optimizing the preoperative analgesic medication regimen, even tapering the opioid dose, or prescribing cognitive, behavioral, or physical therapy prior to elective major surgery like lower extremity joint replacement. During the intraoperative period, anesthetic protocols provide consistent care for surgical patients, and implementing clinical pathways that include regional anesthesia techniques have been shown to decrease perioperative opioid use and improve outcomes. For patients who have surgery, pain has a profound influence on the hospital experience. In the United States, the patient experience of care is one of three domains that influence hospital incentive payment amounts from the Center for Medicare and Medicaid Services. Patient experience is assessed using a survey, and 7 of 32 questions directly or indirectly relate to pain management (5). After the immediate postoperative period, integrated pain management can help patients achieve physical therapy goals and facilitate the transition to after-hospital rehabilitation. For challenging patients with chronic pain, this process may require careful coordination between the in-hospital anesthesiologist, outpatient pain clinic physician, and primary care physician (4).

Thinking Beyond Pain

The practice of anesthesiology in the United States is evolving, and there is a greater emphasis on demonstrating value. Anesthesiologists have historically been successful in establishing perioperative clinical pathways that improve acute pain management especially in orthopedic surgery, and setting up regional anesthesia and acute pain medicine programs has played a key role (6). However, competing priorities require revision of clinical pathways from time to time. For example, concerns regarding quadriceps muscle weakness with femoral nerve blocks (7) and the potential for falls (8) have led to innovations in selective nerve block techniques for knee replacement patients (9) and greater achievements in functional rehabilitation (10). By establishing a PSH model, anesthesiologists have greater opportunity but also greater responsibility for reducing perioperative complications that may or may not typically be considered within the realm of anesthesiology (11).

Future Directions

physical_med_rehab_indexTo date, anesthetic interventions focused on targeting acute pain have not demonstrated long-term functional benefits (12,13). Perhaps implementation of a PSH with better care coordination that includes individualized preoperative preparation and follow-up after surgery during rehabilitation will have greater potential for positive long-term outcomes. In addition to improvements in functional outcomes, a PSH may be able to provide patients a smoother transition from hospital to home in terms of pain management and decrease the incidence of chronic pain after common elective procedures like joint replacement (14). Finally, more health economic research is needed to prove the financial benefits of a PSH in terms of cost savings for hospitals.

In summary, the PSH is a model that can be applied many ways to provide coordinated care of the surgical patient from the decision to proceed with surgery through convalescence. Pain medicine plays an integral role in any PSH implementation. However, to be effective, anesthesiologists as leaders of the PSH need to target improvement strategies beyond pain outcomes and the immediate postoperative period.

References

  1. Berwick DM, Nolan TW, Whittington J: The triple aim: care, health, and cost. Health Aff (Millwood) 2008; 27: 759-69
  2. Vetter TR, Boudreaux AM, Jones KA, Hunter JM, Jr., Pittet JF: The perioperative surgical home: how anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg 2014; 118: 1131-6
  3. Mariano ER, Walters TL, Kim TE, Kain ZN: Why the perioperative surgical home makes sense for veterans affairs health care. Anesth Analg 2015; 120: 1163-6
  4. Walters TL, Mariano ER, Clark JD: Perioperative Surgical Home and the Integral Role of Pain Medicine. Pain Med 2015; 16: 1666-72
  5. Mariano ER, Miller B, Salinas FV: The expanding role of multimodal analgesia in acute perioperative pain management. Adv Anesth 2013; 31: 119-136
  6. Mariano ER: Making it work: setting up a regional anesthesia program that provides value. Anesthesiol Clin 2008; 26: 681-92, vi
  7. Charous MT, Madison SJ, Suresh PJ, Sandhu NS, Loland VJ, Mariano ER, Donohue MC, Dutton PH, Ferguson EJ, Ilfeld BM: Continuous femoral nerve blocks: varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block. Anesthesiology 2011; 115: 774-81
  8. Feibel RJ, Dervin GF, Kim PR, Beaule PE: Major complications associated with femoral nerve catheters for knee arthroplasty: a word of caution. J Arthroplasty 2009; 24: 132-7
  9. Lund J, Jenstrup MT, Jaeger P, Sorensen AM, Dahl JB: Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery: preliminary results. Acta Anaesthesiol Scand 2011; 55: 14-9
  10. Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, Ganaway T, King R, Mariano ER: Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2014; 472: 1377-83
  11. Kim TE, Mariano ER: Developing a Multidisciplinary Fall Reduction Program for Lower-Extremity Joint Arthroplasty Patients. Anesthesiol Clin 2014; 32: 853-864
  12. Ilfeld BM, Ball ST, Gearen PF, Mariano ER, Le LT, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Maldonado RC, Meyer RS: Health-related quality of life after hip arthroplasty with and without an extended-duration continuous posterior lumbar plexus nerve block: a prospective, 1-year follow-up of a randomized, triple-masked, placebo-controlled study. Anesth Analg 2009; 109: 586-91
  13. Ilfeld BM, Shuster JJ, Theriaque DW, Mariano ER, Girard PJ, Loland VJ, Meyer S, Donovan JF, Pugh GA, Le LT, Sessler DI, Ball ST: Long-term pain, stiffness, and functional disability after total knee arthroplasty with and without an extended ambulatory continuous femoral nerve block: a prospective, 1-year follow-up of a multicenter, randomized, triple-masked, placebo-controlled trial. Reg Anesth Pain Med 2011; 36: 116-20
  14. Lavand’homme PM, Grosu I, France MN, Thienpont E: Pain trajectories identify patients at risk of persistent pain after knee arthroplasty: an observational study. Clin Orthop Relat Res 2014; 472: 1409-15

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To the Next Generation of Physician Leaders

I was recently invited to visit an academic anesthesiology department to speak to the residents about becoming a leader (see SlideShare). In addition to recognizing the honor and privilege of addressing this important topic with the next generation of physician anesthesiologists, I had two other initial thoughts: 1) I must be getting old; and 2) This isn’t going to be easy.

Balloon FiestaI came up with a short list of lessons that I’ve learned over the years. While some examples I included are anesthesiology-specific, the lessons themselves are not. Please feel free to edit, adapt, and add to this list; then disseminate it to the future physician leaders who will one day take our places.

  1. First and foremost, be a good doctor. Always remember that we as physicians take an oath. In the modern version of the Hippocratic Oath commonly recited at medical school graduations today, we say, “May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.” As a physician anesthesiologist, we care for the most vulnerable of patients—those who under anesthesia cannot care for themselves. Examples of anesthesiologists who do not honor their calling exist in the news and even scientific journals, but we cannot follow this path. 

     

  2. Define your identity. We live in the era of the “provider,” and this sometimes causes role confusion from the perspective of our patients. Team PhotoWe also don’t tend to do ourselves any favors. How many times have you heard someone say, “Hi I’m [first name only] with anesthesia”? According to the American Society of Anesthesiologists newsletter, approximately 60% of the public may not know that physician anesthesiologists go to medical school. While every member of the anesthesia care team plays a crucial role, the next level of non-physician provider in this model has one-tenth the amount of clinical training when compared to a physician anesthesiologist at graduation. I’ve written before about what I love about being an anesthesiologist, and being the physician whom patients trust to keep them safe during surgery is a privilege which comes with a great deal of responsibility.
  3. Consider the “big picture.” The health care enterprise is constantly evolving. Today, the emphasis is on value and not volume. Value takes into account quality and cost with the highest quality care at the lowest cost being the ultimate goal. The private practice model of anesthesiology has changed dramatically in the last few years with the growth of “mega-groups” created by vertical and horizontal integration of smaller practices and sometimes purchased by private investors. In this environment, physician anesthesiologists and anesthesiology groups will have to consider ways they can add value, improve the patient experience, and reduce costs of care in order to stay relevant and competitive.
  4. Promote positive change. Observe, ask questions, hypothesize solutions, collect data, evaluate results, draw conclusions, and form new hypotheses—these are all elements of the scientific method and clinical medicine. These steps are also common to process improvement, making physicians perfectly capable of system redesign. The key is establishing your team’s mission and vision, strategic planning and goal-setting, and regularly evaluating progress. Books have been written on these subjects, so I can’t do these topics justice here. In my opinion, physicians offer an important and necessary perspective that cannot be lost as healthcare becomes more and more business-like.
  5. Be open to opportunities. Thomas Edison said, “Opportunity is missed by most people because it is dressed in overalls and looks like work.” I have written previously about the merits of saying yes. As a resident or new staff physician, it often seems impossible to get involved. However, most hospital committee meetings are open to guests. Consider going to one that covers a topic of interest and volunteer for a task if the opportunity presents itself. In addition, many professional societies invite members to self-nominate for committees or submit proposals for educational activities at their annual meetings.
  6. IMG_7673Thank your team. Taking the first steps on the path to leadership is not going to be easy. There will be many obstacles, not the least of which is time management. A high-functioning healthcare team of diverse backgrounds, skills, and abilities will accomplish much more than what an individual can do alone. Celebrate team wins. Respect each team member’s opinion even when it differs from yours.

A good leader should earn the trust of his or her team every day.

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Multimodal Pain Relief after Knee Replacement

Knee-pain 2Knee replacement is one of the most commonly performed operations in the United States with over 700,000 procedures performed annually (1). Besides providing anesthesia care in the operating room, anesthesiologists are dedicated to providing the best perioperative pain management in order to improve patients’ function and facilitate rehabilitation after surgery. In the past, pain management was limited to the use of opioids (narcotics). Opioids only attack pain in one way, and just adding more opioids does not usually lead to better pain control.

In 2012, the American Society of Anesthesiologists (ASA) published its guidelines for acute pain management in the perioperative setting (2). This document recommends “multimodal analgesia” which means that two or more classes of pain medications or therapies, working with different mechanisms of action, should be used in the treatment of acute pain.

While opioids are still important pain medications, they should be combined with other classes of medications known to help relieve postoperative pain unless contraindicated. These include:

  • Non-steroidal anti-inflammatory drugs (NSAIDs): Examples include ibuprofen, diclofenac, ketorolac, celecoxib. NSAIDs act on the prostaglandin system peripherally and work to decrease inflammation.
  • Acetaminophen: Acetaminophen acts on central prostaglandin synthesis and provides pain relief through multiple mechanisms.
  • Gabapentinoids: Examples include gabapentin and pregabalin. These medications are membrane stabilizers that essentially decrease nerve firing.

The ASA also strongly recommends the use of regional analgesic techniques as part of the multimodal analgesic protocol when indicated.

Epidural Analgesia

When compared to opioids alone, epidural analgesia produces lower pain scores and shorter time to achieve physical therapy goals (3). However, higher dose of local anesthetic (numbing medicine) may lead to muscle weakness that can limit activity (4). In addition, epidural analgesia can lead to common side effects (urinary retention, dizziness, itchiness) and is not selective for the operative leg, meaning that the non-operative leg may also become numb.

Femoral Nerve Block

A peripheral nerve block of the femoral nerve is specific to the operative leg. When compared to opioids alone, a femoral nerve block provides better pain control and leads to higher patient satisfaction (5). One area of controversy is whether a single-injection nerve block or catheter-based technique is preferred. There is evidence to support the use of continuous nerve block catheters to extend the pain relief and opioid-sparing benefits of nerve blocks in patients having major surgery like knee replacement. When a continuous femoral nerve block catheter is used, the pain relief is comparable to an epidural but without the epidural-related side effects (6). One legitimate concern raised over the use of femoral nerve blocks in knee replacement patients is the resulting quadriceps muscle weakness (7).

From Gray's Anatomy
From Gray’s Anatomy

Saphenous Nerve Block (Adductor Canal Block)

The saphenous nerve is the largest sensory branch of the femoral nerve and can be blocked within the adductor canal to provide postoperative pain relief and facilitate rehabilitation (8, 9). In healthy volunteers, quadriceps strength is better preserved when subjects receive an adductor canal block compared to a femoral nerve block (10).

In actual knee replacement patients, quadriceps function decreases regardless of nerve block type after surgery but to a lesser degree with adductor canal blocks (11). Recently there have been reports of quadriceps weakness resulting from adductor canal blocks and catheters that have affected clinical care (12, 13).

Fall Risk

According to a large retrospective study of almost 200,000 cases, the incidence of inpatient falls for patients after TKA is 1.6%, and perioperative use of nerve blocks is not associated with increased risk (14). Patient factors that increase the risk of falls include higher age, male sex, sleep apnea, delirium, anemia requiring blood transfusion, and intraoperative use of general anesthesia (14). The bottom line is that all knee replacement patients are at increased risk for falling due to multiple risk factors, and any clinical pathway should include fall prevention strategies and an emphasis on patient safety.

Other Local Anesthetic Techniques

In addition to a femoral nerve or adductor canal block, a sciatic nerve block is sometimes offered to provide a “complete” block of the leg. There are studies for and against this practice. Arguably, the benefit of a sciatic nerve block does not last beyond the first postoperative day (15). Surgeon-administered local anesthetic around the knee joint (local infiltration analgesia) can be combined with nerve block techniques to provide additional postoperative pain relief for the first few hours after surgery (16, 17).

For more information about anesthetic options for knee replacement, please see my post on My Knee Guide.

References

  1. The Center for Disease Control and Prevention. FastStats: Inpatient Surgery. National Hospital Discharge Survey: 2010 table. http://www.cdc.gov/nchs/fastats/inpatient-surgery.htm. Accessed January 30, 2015.
  2. American Society of Anesthesiologists Task Force on Acute Pain M: Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012, 116(2):248-273.
  3. Mahoney OM, Noble PC, Davidson J, Tullos HS: The effect of continuous epidural analgesia on postoperative pain, rehabilitation, and duration of hospitalization in total knee arthroplasty. Clin Orthop Relat Res 1990(260):30-37.
  4. Raj PP, Knarr DC, Vigdorth E, Denson DD, Pither CE, Hartrick CT, Hopson CN, Edstrom HH: Comparison of continuous epidural infusion of a local anesthetic and administration of systemic narcotics in the management of pain after total knee replacement surgery. Anesth Analg 1987, 66(5):401-406.
  5. Chan EY, Fransen M, Parker DA, Assam PN, Chua N: Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev 2014, 5:CD009941.
  6. Barrington MJ, Olive D, Low K, Scott DA, Brittain J, Choong P: Continuous femoral nerve blockade or epidural analgesia after total knee replacement: a prospective randomized controlled trial. Anesth Analg 2005, 101(6):1824-1829.
  7. Charous MT, Madison SJ, Suresh PJ, Sandhu NS, Loland VJ, Mariano ER, Donohue MC, Dutton PH, Ferguson EJ, Ilfeld BM: Continuous femoral nerve blocks: varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block. Anesthesiology 2011, 115(4):774-781.
  8. Jenstrup MT, Jaeger P, Lund J, Fomsgaard JS, Bache S, Mathiesen O, Larsen TK, Dahl JB: Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: a randomized study. Acta Anaesthesiol Scand 2012, 56(3):357-364.
  9. Hanson NA, Allen CJ, Hostetter LS, Nagy R, Derby RE, Slee AE, Arslan A, Auyong DB: Continuous ultrasound-guided adductor canal block for total knee arthroplasty: a randomized, double-blind trial. Anesth Analg 2014, 118(6):1370-1377.
  10. Kwofie MK, Shastri UD, Gadsden JC, Sinha SK, Abrams JH, Xu D, Salviz EA: The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk: a blinded, randomized trial of volunteers. Reg Anesth Pain Med 2013, 38(4):321-325.
  11. Jaeger P, Zaric D, Fomsgaard JS, Hilsted KL, Bjerregaard J, Gyrn J, Mathiesen O, Larsen TK, Dahl JB: Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med 2013, 38(6):526-532.
  12. Chen J, Lesser JB, Hadzic A, Reiss W, Resta-Flarer F: Adductor canal block can result in motor block of the quadriceps muscle. Reg Anesth Pain Med 2014, 39(2):170-171.
  13. Veal C, Auyong DB, Hanson NA, Allen CJ, Strodtbeck W: Delayed quadriceps weakness after continuous adductor canal block for total knee arthroplasty: a case report. Acta Anaesthesiol Scand 2014, 58(3):362-364.
  14. Memtsoudis SG, Danninger T, Rasul R, Poeran J, Gerner P, Stundner O, Mariano ER, Mazumdar M: Inpatient falls after total knee arthroplasty: the role of anesthesia type and peripheral nerve blocks. Anesthesiology 2014, 120(3):551-563.
  15. Abdallah FW, Brull R: Is sciatic nerve block advantageous when combined with femoral nerve block for postoperative analgesia following total knee arthroplasty? A systematic review. Reg Anesth Pain Med 2011, 36(5):493-498.
  16. Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, Ganaway T, King R, Mariano ER: Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2014, 472(5):1377-1383.
  17. Mariano ER, Kim TE, Wagner MJ, Funck N, Harrison TK, Walters T, Giori N, Woolson S, Ganaway T, Howard SK: A randomized comparison of proximal and distal ultrasound-guided adductor canal catheter insertion sites for knee arthroplasty. J Ultrasound Med 2014, 33(9):1653-1662.

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Hints for Anesthesiology Residency Applicants

Job-InterviewThis post is co-authored by Dr. Kyle Harrison (@KyleHarrisonMD) and has also been featured on CSA Online First.

So, you’ve finished your third year of medical school and have decided that you want to be an anesthesiologist. In our completely biased opinion, you are making the right choice and, at the end of your residency training, you will be in a unique position to enhance the experience and improve the outcomes of patients undergoing surgery and invasive procedures. However, securing a coveted slot in an anesthesiology residency in the United States has never been more competitive. In the many years that we have spent as faculty in academic anesthesiology departments, we have learned a few things about the application process. Our views are our own and do not reflect the official views of any anesthesiology residency program with which we have been affiliated. The following are some (hopefully helpful) answers to common questions that we have been asked over the years.

How High Do My USMLE Score and GPA Have to Be?
Competitive scores are essential. We can’t quote you a number because they vary year to year and program to program, but the trend is only increasing. All medical students, regardless of school, applying in anesthesiology must do well on the USMLE. Think about it — this is the only equalizing factor between schools that teach differently or have different reputations. Having a great score doesn’t guarantee you admission, but if your scores are not competitive, you will have an uphill battle to get a residency slot at a top program. The value of the standardized test score in learning is often debated in academia; however, no one will argue against the conclusion that previous success on standardized tests usually predicts future success on standardized tests. Residency training is demanding. Programs want their residents 100 percent committed and not worrying too much about how they will perform on their annual in-training exams and eventual certification exam.

Do I Need to Have Research Experience?
No program will ever discourage applicants with research experience from applying; we would say that it is not required but is recommended. Don’t do it for the sake of doing it, but definitely do it if you can find a project that you are passionate about. While research in anesthesiology or pain makes sense (shows academic interest in the chosen field), it can really be in any area. It is more impressive to be involved in a project (big or small), see it through, and maybe even present at a meeting or publish in a journal, than to just say you did “research.” If you do list research on your application or curriculum, make sure you can talk about the project, your specific role, and what you learned from it; you will be asked. If you are not interested in research, then consider focusing on another aspect of extracurricular life such as community service.

What Should Be on My List of Extracurricular Activities?
If there is something about you that is really different, it’s helpful to mention it. Again, the application process isn’t perfect, but the file you submit is all the information program coordinators and directors have. If you have done something special — climbed Mt. Everest, set up HIV clinics in Africa, won Olympic medals, had a previous career — or do something noteworthy, such as volunteer extensively in your community, play an instrument, or dance professionally, mention those things. Yes, we have actually seen these applicants (and interviewed them of course)! Selection committee members often apply the “3 a.m. call rule” when reviewing an applicant. This is: Would you like to be on call in the middle of the night with this person? Applicants viewed as hardworking, clinically competent, and interesting to talk to should result in a solid “yes.” If you just like to run in your free time, mentioning that probably doesn’t make a huge difference in the application.

Do I Need to Do an Anesthesiology Rotation?
You should do an anesthesiology rotation at your local institution at the very least. Programs want to know if you understand what you’re getting yourself into. And it does make a difference how well you did on the rotation. Many students approach their anesthesiology rotation as the “intubation and IV insertion” rotation. Most anesthesiologists like us are passionate about their specialty, and the specialty itself in rapidly evolving (familiarize yourself with the Perioperative Surgical Home model). Trust us — we can tell when a student is genuinely interested in anesthesiology, or not. In our experience, medical students who stand out pay attention to what is going on in the perioperative period, anticipate events, know how to be helpful, get involved with the entire patient care episode (starting with the preoperative evaluation, through giving report to the nurse in the recovery room, and even including postoperative follow-up). It is never impressive to see a medical student standing around looking bored. There is always something to do — for example, when a patient arrives in the OR, you can start applying monitors without prompting, or help with positioning. Residents and staff anesthesiologists recognize these things and reward you by getting you more involved with patient care, including procedures.

Who Should Write My Letters of Recommendation?
The dean’s letter is the big one and counts the most. The form of the dean’s letter is usually standardized, so residency program directors have to weed through all the verbiage to get the information they want. It helps when the dean’s letter includes the student’s rank and any special merits (e.g., AOA). Additional letters should be written by faculty members who really know you and can provide helpful content — research mentor, career advisor, staff physician with whom you have worked closely. It doesn’t add strength to an application to have a lot of generic letters (quality over quantity); three strong letters are better than two strong plus three average letters, since the strong letters may get lost in the sea of information in the applicant’s file.

interview-panel-ace

What Else Can I Do to Improve My Chances?
Unfortunately there are no guarantees. The “gatekeeper” is the initial electronic application. With anesthesiology departments receiving hundreds of applications each year, most will sound exactly the same. “I love pharmacology and physiology” (while possibly true for some) only takes you so far. Something unique about the applicant has to come through the pages. Excellent grades and USMLE scores, strong dean’s letter and other recommendations, personal experiences, prior careers, other degrees, thought-provoking research, a list of activities, and a unique personal statement — anything that sets you apart from the pack can make a difference!

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Personalized Medicine: What it Means to be a Physician Anesthesiologist

This post has also been featured on KevinMD.com.

I wear a lot of hats in my job. Though I’m a physician who specializes in the practice of anesthesiology, I don’t spend all day every day at the head of an operating room table.

Team Photo 2Many days I spend in an administrative leadership role or conducting research studies. These functions support the best interests of my patients as well as the science and practice of anesthesiology. On my “clinical” days that I spend in hands-on patient care, I provide anesthesia for patients who undergo surgery and other invasive procedures. I also treat acute pain as a consultant. Some of my colleagues in anesthesiology specialize in chronic pain or critical care medicine.

As a medical student, I had a hard time at first understanding what the physician anesthesiologist does. I saw monitors, complicated equipment, and technical procedures that involved a lot of needles. Thankfully, I worked with resident and attending anesthesiologists who inspired me to pursue this specialty.

Anesthesiology is a unique field within medicine. It is at the same time incredibly cerebral and extremely physical. For example, the physician anesthesiologist must be ready to diagnose heart or lung problems that may complicate the patient’s surgery, and decide which medications are appropriate.

BefoAnesthesiologist-4re administering a medication, it’s not enough just to understand the complex pharmacologic effects of the drug and determine the right dose. The anesthesiologist also has to know how to dilute and prepare the drug, the appropriate route for the medication, which other medications are and are not compatible, and how to program the infusion device. In addition, an anesthesiologist has to be technically skilled at finding veins—sometimes in the hand or arm, sometimes leading centrally to the heart—in order to give the medication in the first place.

I am always aware of the trust that patients and their families give me, a total stranger, and I work hard to earn that trust throughout the perioperative period. The job of the physician anesthesiologist is deeply personal. In the operating room, I care for the most vulnerable of patients—those who, while under anesthesia, cannot care for themselves.

– I constantly listen to the sounds of their hearts.
– I breathe for them when they are unable.
– I keep them warm in the cold operating room.
– I provide the fluids that their bodies need.
– I pad their arms and legs and other pressure points.
– I watch the operation step by step, anticipating and responding.
– I learn from their bodies’ response to anesthesia to give the right amount.
– I prevent and relieve their pain.
– I protect them from dangers of which they are unaware.

I have heard people, my colleagues included, compare physician anesthesiologists to pilots. No one claps when the plane lands, just as no one expects any less than a perfect uncomplicated anesthetic every time. We physician anesthesiologists draw great personal satisfaction from doing what we do, and from providing a unique type of personalized medicine. Our patients and their families depend on us to be at our best, always.

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Time to Rethink Preoperative Preparation

Anesthesia1The concept of preoperative preparation for patients scheduled for surgery requiring anesthesia is not a new one.  In fact, the idea goes back to Dr. Albert Lee’s description in 1949 (1, 2).  Dr. Lee had observed in his day that patients commonly presented for surgery in various states of poor health; it seemed to make more sense to see these patients before surgery to identify areas of concern early and optimize patients’ conditions they went under the knife.

The model of a stand-alone preoperative evaluation clinic, often run by anesthesiology staff, with a “one stop shop” model for patients’ interviews and examinations, testing, education, and referrals really did not take off until the 1990s (3).  This patient-centered care model was intended to improve efficiency by decreasing the run-around that many patients encountered, but it also saved money for the institution by reducing the ordering of unnecessary tests (4) and decreasing day-of-surgery cancellations (4, 5).

Current State
Current State

In the present state (assuming an ACO or HMO model), patients are referred to the surgeon by the primary care physician for evaluation of a problem that may be amenable to surgical correction.  If the surgeon deems the patient a surgical candidate, the patient may receive a scheduled date for surgery and then may be referred to the anesthesiology preoperative evaluation clinic (“preop clinic”) for further work-up.  During this encounter, the provider in the preop clinic may request a variety of tests based on the planned surgery and the patient’s comorbid conditions in order to make appropriate recommendations regarding perioperative management to minimize risks.  The American Society of Anesthesiologists (ASA) has published a recent (2012) practice advisory for preanesthesia evaluation to guide this process.

Unfortunately, after nearly 2 decades of employing this model, day of surgery cancellations still occur at various rates around the world.  Some of the reasons are related to factors that preop clinics were meant to avoid:  inadequate preoperative work-up or change in medical condition (6).  Other reasons are patient-driven:  patients’ not showing up (7) or patients’ changing their minds about having surgery (8).  Although not all of these issues are easily solved, it does make me wonder–perhaps it is time for us to rethink the process of preparing patients for surgery.

In our current state, a patient may hypothetically be scheduled for surgery in 8 weeks, a date agreed upon by the patient and surgeon based on available dates.  Even if a preop clinic visit takes place the same day as the surgery clinic visit, this only allows 2 months to optimize a patient’s chronic medical conditions (e.g., hypertension, diabetes, coronary artery disease) that took years to develop.  Imagine if the timeline was even shorter, like 3 weeks.  Add to this time pressure the tremendous physiologic stress that surgery and the subsequent rehabilitation put on the body, and it is not difficult to see why patients can still be cancelled on the day of surgery when they present with abnormal vital signs or test results, making the risks seem too high.  We would not expect ourselves to run a marathon without adequate training and preparation on short notice–why would we do this to our patients having elective surgery?

Future State
Future State

How can we improve preoperative preparation?  I think it still starts with the primary care physician.  With advances in technology such as telemedicine and e-consults (or low-tech phone calls), we have ways to create a direct interface between primary care physicians and anesthesiologists to discuss advanced preparation of patients who may undergo elective surgical procedures.

This coordinated care model is consistent with ASA’s Perioperative Surgical Home.  Early consultation may involve assessment of a patient’s risks and benefits from the procedure, consideration of alternative treatments, and development of a plan to optimize the patient’s comorbid conditions, medication management, and nutrition.  Strong for Surgery is a program that provides patients and clinicians useful checklists based on best-available evidence to guide early preoperative preparation related to smoking cessation, nutrition, glycemic control, and medication management.  For elective surgery, the decision when to refer the patient to a surgeon can be made jointly by the primary care physician and anesthesiologist.  Prior to surgery, the preop clinic visit should still take place, but the focus no longer needs to be on information-gathering and ordering a battery of tests; rather, the goals should be to review pertinent instructions, preview the perioperative experience for patients, and address any logistical or scheduling issues raised by patients to prevent their not showing up or changing their minds at the last minute.  Let’s get started.

For more information, check out this brilliant and inspiring video from the Royal College of Anaesthetists “Perioperative Medicine:  the Pathway to Better Surgical Care.

REFERENCES

  1. Lee JA. The anaesthetic out-patient clinicAnaesthesia. 1949 Oct;4(4):169-74.

  2. Yen C, Tsai M, Macario A. Preoperative evaluation clinicsCurr Opin Anaesthesiol. 2010 Apr;23(2):167-72.

  3. Fischer SP. Cost-effective preoperative evaluation and testingChest. 1999 May;115(5 Suppl):96S-100S.

  4. Fischer SP. Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospitalAnesthesiology. 1996 Jul;85(1):196-206.

  5. Ferschl MB, Tung A, Sweitzer B, Huo D, Glick DB. Preoperative clinic visits reduce operating room cancellations and delaysAnesthesiology. 2005 Oct;103(4):855-9.

  6. Xue W, Yan Z, Barnett R, Fleisher L, Liu R. Dynamics of Elective Case Cancellation for Inpatient and Outpatient in an Academic CenterJ Anesth Clin Res. 2013 May 1;4(5):314.

  7. Kumar R, Gandhi R. Reasons for cancellation of operation on the day of intended surgery in a multidisciplinary 500 bedded hospital. J Anaesthesiol Clin Pharmacol. 2012 Jan;28(1):66-9.

  8. Caesar U, Karlsson J, Olsson LE, Samuelsson K, Hansson-Olofsson E. Incidence and root causes of cancellations for elective orthopaedic procedures: a single center experience of 17,625 consecutive casesPatient Saf Surg. 2014 Jun 2;8:24.

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